APPENDIX F - Self Certification Checklist.pdf

Appendix F SBIR/STTR Self Certification Checklist

General Services Administration

Assisted Acquisition Services, Innovation

47QFCA-24-R-0036

The intent of this page is to serve as a checklist to aid offerors in ensuring proposals are conforming to the requirements set forth in the solicitation. This checklist is not intended to cover every requirement in the solicitation but does cover the most common mistakes. This checklist shall be submitted as part of your proposal submission in accordance with Section 3.3 and 6.1, and it is highly encouraged that offerors use this checklist to self-validate the responsiveness of the proposal prior to submission.

Digital Forms: Many of the forms needed to complete a proposal in response to this solicitation are online fillable forms and can be found in Section 2.2 as indicated in the Solicitation.

1.Complete five registrations before submitting your application (Addressed under Business Proposal below) The registration process alone may take six to eight weeks, so it’s important to start as early as possible. All of these registrations must be completed prior to the application being submitted.

● Dun and Bradstreet Universal Numbering System (DUNS)

● Employer Identification Number (EIN)

● System for Award Management (SAM) o Make sure your SAM registration is up to date and your SAM profile allows for the award of “contracts” or “all awards” (this is a contract, not a grant!)

● Small Business Administration Company Registry (SBA)

● Registration in GSA ASSIST (Section 3.1.1)

(http://assist.gsa.gov/assist-web/registration/contractor/search)

2. Make sure you complete all of the following.

● SBIR/STTR PHASE I PROPOSAL

A SBIR/STTR Phase I proposal consists of a Technical Proposal (Appendix A) and a Business Proposal (Appendix B).

⬜ COMPLETED Appendix A – Technical Proposal ⬜ Utilize 47QFCA-24-R-0036 Appendix A

⬜ Appendix A.1 Human Subjects & Clinical Trials Form REQUIRED for ALL proposals (Section 3.4.1)

Appendix F - 47QFCA-24-R-0036 https://fedgov.dnb.com/webform/ https://www.irs.gov/businesses/small-businesses-self-employed/apply-for-an-employer-identification-number-ein-online https://www.sam.gov/SAM/ https://www.sbir.gov/registration?utm_source=WhatCounts+Publicaster+Edition&utm_medium=email&utm_campaign=Final+Reminder%3a+August+5+Deadline+for+Small+Business+Funding+Opportunities&utm_content=SBA+Company+Registry

⬜ Appendix A.2 Study Record to Human Subjects & Clinical Trials Form (Section 3.4.1 if applicable and section below) ⬜ Proposal does not exceed the page and/or word limitations set forth in the Appendix

● Section 4.1 Failure to comply shall result in the proposal being deemed non-responsive per the SBIR Policy Directive dated May 2023, and not considered for award.

⬜ Abstract of Research Plan (< 200 words) ⬜ Keywords (8 words MAX) ⬜ Abstract of Research Impact (< 50 words) ⬜ Potential Commercial Application of Research (< 50 words) ⬜ Statement of Work (< 3 pages) ⬜ Objective (<250 words) ⬜ Research Plan (< 8 pages with summary of potential Commercial Applications) ⬜ Subcontractor/Consultants (letters are excluded from the research plan page limit) ⬜ The Principal Investigator will be employed by the company at the time of award and for the duration of the award (Section 1.4.3) ⬜ Statement of Dual Use Research of Concern (Section 2.2.7) ⬜ Period of Performance adhered to in accordance with Section 3.5.1 and Section 9 of the Solicitation ⬜ Acknowledgement of ALL Amendments issued to Solicitation (either via signature on ALL SF30s AND/OR by Acknowledgement of ALL Amendments on the Technical Proposal (see Summary and Data Record section in appendix A or C)

● ⬜ COMPLETED Appendix B – Business Proposal ⬜ Utilize 47QFCA-24-R-0036 Appendix B

⬜ Provided Dun and Bradstreet Universal Numbering System (DUNS)

⬜ Provided Employer Identification Number (EIN)

⬜ Offeror has registered in System for Award Management (SAM)(section 2.1.1)

⬜ Attached Proof of Registration Small Business Administration Company Registry (SBA) (Section 2.1.2, 3.5)

⬜ Offeror has registered in GSA ASSIST (Section 3.1.1, 3.5) (http://assist.gsa.gov/assist-web/registration/contractor/search)

⬜ Attached SBIR VCOC Application Certification (Section 2.2.5, 3.5 if applicable)

⬜ The total cost proposed is within the SBIR/STTR Approved thresholds set forth in the Solicitation (Section 9, Budget).

⬜Profit does not exceed 7%

Appendix F - 47QFCA-24-R-0036 https://fedgov.dnb.com/webform/ https://www.irs.gov/businesses/small-businesses-self-employed/apply-for-an-employer-identification-number-ein-online https://www.sam.gov/SAM/ https://www.sbir.gov/registration?utm_source=WhatCounts+Publicaster+Edition&utm_medium=email&utm_campaign=Final+Reminder%3a+August+5+Deadline+for+Small+Business+Funding+Opportunities&utm_content=SBA+Company+Registry http://assist.gsa.gov/assist-web/registration/contractor/search

⬜Meet the SBIR/STTR performance requirements set forth in Section 1.4.4 Performance Requirements

⬜ COMPLETED FAR 52.204-24 Representations Regarding Certain Telecom/Video cert (Sections 2.2.6 // 2.2.8 // Business Proposal//Offerors must check the check boxes located in paragraph (d)(1) and (2))

⬜ COMPLETED FAR 52.204-26 Covered Telecom (Sections 2.2.6 // 2.2.8 // Business Proposal//Offerors must check the check boxes located in paragraph (c)(1) and (2))

⬜ COMPLETED SBIR or STTR Funding Agreement Certification (Sections 2.2.3, 3.5/ SBIR/STTR Funding Agreement Form)

⬜ COMPLETED Disclosure of Foreign Relations Form (Section 2.2, 3.5)

⬜ All work will be performed in the United States, unless a waiver has been submitted and granted in advance by the Contracting Officer. All supplies, materials, and equipment must be American made unless a waiver has been granted by the Contracting Officer.

● SBIR/STTR PHASE II PROPOSAL

A SBIR/STTR Phase II proposal consists of a Technical Proposal (Appendix C) and a Business Proposal (Appendix D).

⬜ COMPLETED Appendix C – Technical Proposal ⬜ Utilize 47QFCA-24-R-0036 Appendix C

⬜ Appendix A.1 Human Subjects & Clinical Trials Form REQUIRED for ALL proposals (Section 3.4.1) ⬜ Appendix A.2 Study Record to Human Subjects & Clinical Trials Form (Section 3.4.1 if applicable and section below) ⬜ Proposal does not exceed the page and/or word limitations set forth in the Appendix

● Section 4.1 Failure to comply shall result in the proposal being deemed non-responsive per the SBIR Policy Directive dated May 2023, and not considered for award.

⬜ Abstract of Research Plan (< 200 words) ⬜ Keywords (8 words MAX) ⬜ Abstract of Research Impact (< 50 words) ⬜ Potential Commercial Application of Research (< 50 words) ⬜ Statement of Work (< 5 pages) ⬜ Objective (<250 words) ⬜ Research Plan (< 10 pages) ⬜ Commercialization Plan (< 4 pages) ⬜ Key Personnel (resumes and letters are excluded from the research plan page limit).

⬜ Subcontractor/Consultants (letters are excluded from the research plan page limit)

Appendix F - 47QFCA-24-R-0036

⬜ The Principal Investigator will be employed by the company at the time of award and for the duration of the award (Section 1.4.3) ⬜ Statement of Dual Use Research of Concern (Section 2.2.7) ⬜ Period of Performance adhered to in accordance with Section 3.5.1 and Section 9 of the Solicitation ⬜ Acknowledgement of ALL Amendments issued to Solicitation (either via signature on ALL SF30s AND/OR by Acknowledgement of ALL Amendments on the Technical Proposal (see Summary and Data Record section in appendix A or C)

● ⬜ COMPLETED Appendix D – Business Proposal o ⬜ Utilize 47QFCA-24-R-0036 Appendix D ⬜ Dun and Bradstreet Universal Numbering System (DUNS)

⬜ Employer Identification Number (EIN)

⬜ Offeror has registered in System for Award Management (SAM)(section 2.1.1)

⬜ Attached Proof of Registration Small Business Administration Company Registry (SBA) (Section 2.1.2, 3.5)

⬜ Offeror has registered in GSA ASSIST (Section 3.1.1, 3.5) (http://assist.gsa.gov/assist-web/registration/contractor/search)

⬜ SBIR VCOC Application Certification (Section 2.2.5, 3.5 if applicable)

⬜ The total cost proposed is within the SBIR/STTR Approved thresholds set forth in the Solicitation. (Section 9, budget)

⬜ Profit does not exceed 7%

⬜Meet the SBIR/STTR performance requirements set forth in Section 1.4.4 Performance Requirements

⬜ COMPLETED FAR 52.204-24 Representations Regarding Certain Telecom/Video cert (Sections 2.2.6 // 2.2.8 // Business Proposal Offerors must check the check boxes located in paragraph (d)(1) and (2))

⬜ COMPLETED FAR 52.204-26 Covered Telecom (Sections 2.2.6 // 2.2.8 // Business Proposal /Offerors must check the check boxes located in paragraph (c)(1) and (2))

⬜ COMPLETED SBIR or STTR Funding Agreement Certification (Sections 2.2.3, 3.5/ SBIR/STTR Funding Agreement Form

⬜ COMPLETED Disclosure of Foreign Relations Form (Section 2.2, 3.5)

⬜ All work will be performed in the United States, unless a waiver has been submitted and granted in advance by the Contracting Officer. All supplies, materials, and

Appendix F - 47QFCA-24-R-0036 https://fedgov.dnb.com/webform/ https://www.irs.gov/businesses/small-businesses-self-employed/apply-for-an-employer-identification-number-ein-online https://www.sam.gov/SAM/ https://www.sbir.gov/registration?utm_source=WhatCounts+Publicaster+Edition&utm_medium=email&utm_campaign=Final+Reminder%3a+August+5+Deadline+for+Small+Business+Funding+Opportunities&utm_content=SBA+Company+Registry http://assist.gsa.gov/assist-web/registration/contractor/search equipment must be American made unless a waiver has been granted by the Contracting Officer.

● SBIR/STTR FAST TRACK PROPOSAL

A SBIR/STTR Fast-Track proposal consists of both a complete Phase I proposal and a separate, complete Phase II proposal. To identify the submission as a Fast Track proposal, check the box marked “Yes,” next to the words “Fast Track Proposal” shown on the Phase I and Phase II appendices.

● A.2 PHS Human Subjects and Clinical Trials information – IF APPLICABLE The attachments below may or may not be required depending on whether your study involves Human Subjects or is a Clinical Trial. Refer to Solicitation Section 3.4 and applicable Appendices.

⬜ Inclusion of women, minorities and children ⬜ Recruitment and retention plan ⬜ Study timeline ⬜ Inclusion enrollment report(s) ⬜ Protection of human subjects ⬜ Data and safety monitoring plan ⬜ Overall structure of the study team ⬜ Statistical design and power ⬜ Dissemination Plan ⬜ Other Clinical Trial-related Attachments

● PHS Assignment Request Form Complete as appropriate.

Appendix F - 47QFCA-24-R-0036